Do You Have Any Drug Allergies Or Have You Ever Had An Adverse Reaction To Any Medication?

If So, What?

Have You Ever Responded Adversely To Medical Or Dental Treatment?

Are You Taking Any Medication At This Time?

If So, What?

Are You Under The Care Of A Physician?

Yes

No

For What Conditions?

If Patient Is A Child, What Is His/Her Weight?

(Women) Do You Suspect You Are Pregnant?

Yes

No

Are You Nursing?

Yes

No

Is There Anything Else We Should Know About Your Medical History?

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions I may have made in the completion of this form. I understand I am being treated by an independent contractor and will hold Nikhita Shree Kumar, INC. and Consumer Dental Care Center harmless.

Date

Signature

At Consumers Dental, we have one primary goal, to provide our patients with the highest standard of personalized dental care that truly caters to the consumer.